Case 1:14-cv-02396-PGG-SN Document 304-1 Filed 04/24/24 Page 1 of 10
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`U n i t e d S t a t e s Di s t r i c t C o u r t
`S o u t h e r n Di s t r i c t o f Ne w Y o r k
`
`Ruby J. Krajick
`Clerk of Court
`
`Dear Litigant:
`
`Enclosed is a copy of the judgment entered in your case. If you disagree with a judgment or
`final order of the district court, you may appeal to the United States Court of Appeals for
`the Second Circuit. To start this process, file a “Notice of Appeal” with this Court’s Pro Se
`Intake Unit.
`
`You must file your notice of appeal in this Court within 30 days after the judgment or order
`that you wish to appeal is entered on the Court’s docket, or, if the United States or its officer
`or agency is a party, within 60 days after entry of the judgment or order. If you are unable
`to file your notice of appeal within the required time, you may make a motion for extension
`of time, but you must do so within 60 days from the date of entry of the judgment, or
`within 90 days if the United States or its officer or agency is a party, and you must show
`excusable neglect or good cause for your inability to file the notice of appeal by the
`deadline.
`
`Please note that the notice of appeal is a one-page document containing your name, a
`description of the final order or judgment (or part thereof) being appealed, and the name of
`the court to which the appeal is taken (the Second Circuit) – it does not include your reasons
`or grounds for the appeal. Once your appeal is processed by the district court, your notice
`of appeal will be sent to the Court of Appeals and a Court of Appeals docket number will
`be assigned to your case. At that point, all further questions regarding your appeal must be
`directed to that court.
`
`The filing fee for a notice of appeal is $605 payable in cash, by bank check, certified check,
`or money order, to “Clerk of Court, S.D.N.Y.” No personal checks are accepted. Please see
`District Court fee schedule at https://www.nysd.uscourts.gov/programs/fees. If you are
`unable to pay the $605 filing fee, complete the “Motion to Proceed in Forma Pauperis on
`Appeal” form and submit it with your notice of appeal to the Pro Se Intake Unit. If the
`district court denies your motion to proceed in forma pauperis on appeal, or has certified
`under 28 U.S.C. ' 1915(a)(3) that an appeal would not be taken in good faith, you may file a
`motion in the Court of Appeals for leave to appeal in forma pauperis, but you must do so
`within 30 days after service of the district court order that stated that you could not
`proceed in forma pauperis on appeal.
`
`For additional issues regarding the time for filing a notice of appeal, see Federal Rule of
`Appellate Procedure 4(a). There are many other steps to beginning and proceeding with
`your appeal, but they are governed by the rules of the Second Circuit Court of Appeals and
`the Federal Rules of Appellate Procedure. For more information, visit the Second Circuit
`Court of Appeals website at http://www.ca2.uscourts.gov/.
`T H E D A N I E L P A T R I C K M O Y N I H A N
`T H E C H A R L E S L . B R I E A N T , J R .
`U N I T E D S T A T E S C O U R T H O U S E
`U N I T E D S T A T E S C O U R T H O U S E
`5 0 0 P E A R L S T R E E T
`3 0 0 Q U A R R O P A S S T R E E T
`N E W Y O R K , N Y 1 0 0 0 7 - 1 3 1 2
`W H I T E P L A I N S , N Y 1 0 6 0 1 - 4 1 5 0
`Rev. 5/23/14
`
`

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`Case 1:14-cv-02396-PGG-SN Document 304-1 Filed 04/24/24 Page 2 of 10
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`UNITED STATES DISTRICT COURT
`SOUTHERN DISTRICT OF NEW YORK
`
`
`
`
`
`
`(List the full name(s) of the plaintiff(s)/petitioner(s).)
`
`_____CV________ ( )( )
`
`-against-
`
`NOTICE OF APPEAL
`
`
`
`
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`(List the full name(s) of the defendant(s)/respondent(s).)
`
`Notice is hereby given that the following parties:
`
`
`
`
`
`
`(list the names of all parties who are filing an appeal)
`
`in the above-named case appeal to the United States Court of Appeals for the Second Circuit
`
`from the  judgment  order
`
`that:
`
`
`
`
`
`entered on:
`
`
`(date that judgment or order was entered on docket)
`
`(If the appeal is from an order, provide a brief description above of the decision in the order.)
`
`
`
`
`Dated
`
`
`Name (Last, First, MI)
`
`
`Address
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`
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`Telephone Number
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`Signature*
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`City
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`State
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`Zip Code
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`E-mail Address (if available)
`
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`* Each party filing the appeal must date and sign the Notice of Appeal and provide his or her mailing address and telephone
`number, EXCEPT that a signer of a pro se notice of appeal may sign for his or her spouse and minor children if they are parties
`to the case. Fed. R. App. P. 3(c)(2). Attach additional sheets of paper as necessary.
`Rev. 12/23/13
`
`
`

`

`Case 1:14-cv-02396-PGG-SN Document 304-1 Filed 04/24/24 Page 3 of 10
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`UNITED STATES DISTRICT COURT
`SOUTHERN DISTRICT OF NEW YORK
`
`
`
`
`
`
`(List the full name(s) of the plaintiff(s)/petitioner(s).)
`
`-against-
`
`
`
`
`
`(List the full name(s) of the defendant(s)/respondent(s).)
`
`_____CV________ ( )( )
`
`MOTION FOR EXTENSION
`OF TIME TO FILE NOTICE
`OF APPEAL
`
` I
`
` move under Rule 4(a)(5) of the Federal Rules of Appellate Procedure for an extension of time
`
`to file a notice of appeal in this action. I would like to appeal the judgment
`
`entered in this action on
`
` but did not file a notice of appeal within the required
`
`time period because:
`
`
`
`
`date
`
`
`
`
`
`(Explain here the excusable neglect or good cause that led to your failure to file a timely notice of appeal.)
`
`
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`
`
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`
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`
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`Signature
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`City
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`State
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`Zip Code
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`E-mail Address (if available)
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`
`Dated:
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`Name (Last, First, MI)
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`
`
`
`Address
`
`
`Telephone Number
`
`
`Rev. 3/27/15
`
`
`

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`Case 1:14-cv-02396-PGG-SN Document 304-1 Filed 04/24/24 Page 4 of 10
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`UNITED STATES DISTRICT COURT
`SOUTHERN DISTRICT OF NEW YORK
`
`
`
`
`
`
`(List the full name(s) of the plaintiff(s)/petitioner(s).)
`
`-against-
`
`
`
`
`
`(List the full name(s) of the defendant(s)/respondent(s).)
`
`_____CV_________ ( )( )
`
`MOTION FOR LEAVE TO
`PROCEED IN FORMA
`PAUPERIS ON APPEAL
`
`I move under Federal Rule of Appellate Procedure 24(a)(1) for leave to proceed in forma
`
`pauperis on appeal. This motion is supported by the attached affidavit.
`
`
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`
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`Signature
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`City
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`
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`State
`
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`Zip Code
`
`E-mail Address (if available)
`
`
`
`
`Dated
`
`
`Name (Last, First, MI)
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`
`
`
`Address
`
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`Telephone Number
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`Rev. 12/23/13
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`
`

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`Case 1:14-cv-02396-PGG-SN Document 304-1 Filed 04/24/24 Page 5 of 10
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`Application to Appeal In Forma Pauperis
`
`
`
`
`
`______________________v. ______________________
`
`
`
`
`
`
`Appeal No. __________________
`
`District Court or Agency No. _________________
`
`Instructions
`
`Complete all questions in this application and then
`sign it. Do not leave any blanks: if the answer to a
`question is "0," "none," or "not applicable (N/A),"
`write that response. If you need more space to answer
`a question or to explain your answer, attach a separate
`sheet of paper identified with your name, your case's
`docket number, and the question number.
`
`
` Date: _____________________________
`
`
`
`Affidavit in Support of Motion
`
` I
`
` swear or affirm under penalty of perjury that,
`because of my poverty, I cannot prepay the docket
`fees of my appeal or post a bond for them. I believe
`I am entitled to redress. I swear or affirm under
`penalty of perjury under United States laws that my
`answers on this form are true and correct. (28
`U.S.C. § 1746; 18 U.S.C. § 1621.)
`
`
` Signed: _____________________________
`
`
`My issues on appeal are: (required):
`
`
`
`
`
`
`1.
`
`For both you and your spouse estimate the average amount of money received from each
`of the following sources during the past 12 months. Adjust any amount that was received
`weekly, biweekly, quarterly, semiannually, or annually to show the monthly rate. Use
`gross amounts, that is, amounts before any deductions for taxes or otherwise.
`
`
`
`Income source
`
`Employment
`Self-employment
`Income from real property (such as
`rental income)
`
`Average monthly
`amount during the past
`12 months
`You
`$
`$
`$
`
`Spouse
`$
`$
`$
`
`Amount expected next
`month
`
`You
`$
`$
`$
`
`Spouse
`$
`$
`$
`
`12/01/2013 SCC
`
`
`- 1 -
`
`

`

`Case 1:14-cv-02396-PGG-SN Document 304-1 Filed 04/24/24 Page 6 of 10
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`Interest and dividends
`Gifts
`Alimony
`Child support
`Retirement (such as social security,
`pensions, annuities, insurance)
`Disability (such as social security,
`insurance payments)
`Unemployment payments
`Public-assistance (such as welfare)
`Other (specify):
`
` Total monthly income:
`
`
`$
`$
`$
`$
`$
`
`$
`
`$
`$
`$
`
`$
`
`$
`$
`$
`$
`$
`
`$
`
`$
`$
`$
`
`$
`
`$
`$
`$
`$
`$
`
`$
`
`$
`$
`$
`
`$
`
`$
`$
`$
`$
`$
`
`$
`
`$
`$
`$
`
`$
`
`
`
`2.
`
`
`
`List your employment history for the past two years, most recent employer first. (Gross
`monthly pay is before taxes or other deductions.)
`
`Employer
`
`Address
`
`Dates of
`employment
`
`
`
`
`Gross
`monthly pay
`$
`$
`$
`
`
`
`
`
`
`
`
`
`
`3.
`
`
`
`List your spouse's employment history for the past two years, most recent employer first.
`(Gross monthly pay is before taxes or other deductions.)
`
`Employer
`
`Address
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`- 2 -
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`Dates of
`employment
`
`
`
`
`Gross
`monthly pay
`$
`$
`$
`
`

`

`Case 1:14-cv-02396-PGG-SN Document 304-1 Filed 04/24/24 Page 7 of 10
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`
`4.
`
`
`
`
`How much cash do you and your spouse have? $________
`
`Below, state any money you or your spouse have in bank accounts or in any other
`financial institution.
`
`Financial Institution
`
`Type of Account
`
`
`
`
`
`
`
`
`
`Amount you have Amount your
`spouse has
`$
`$
`$
`
`$
`$
`$
`
`
`If you are a prisoner seeking to appeal a judgment in a civil action or proceeding, you must
`attach a statement certified by the appropriate institutional officer showing all receipts,
`expenditures, and balances during the last six months in your institutional accounts. If you
`have multiple accounts, perhaps because you have been in multiple institutions, attach one
`certified statement of each account.
`
`
`5.
`
`List the assets, and their values, which you own or your spouse owns. Do not list clothing
`and ordinary household furnishings.
`
`
`
`
`
`
`
`
`
`
`
`
`Home
`(Value) $
`
`
` Other real estate
`(Value) $
`
`
`Motor vehicle #2
`(Value) $
`Make and year:
`Model:
`Registration #:
`
` Other assets
`(Value) $
`
`
`
`
`
`
` Motor vehicle #1
`(Value) $
`Make and year:
`Model:
`Registration #:
`
`Other assets
`(Value) $
`
`
`
`
`- 3 -
`
`

`

`Case 1:14-cv-02396-PGG-SN Document 304-1 Filed 04/24/24 Page 8 of 10
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`
`6.
`
`
`
`State every person, business, or organization owing you or your spouse money, and the
`amount owed.
`
`Person owing you or your spouse
`money
`
`
`
`
`
`Amount owed to you
`
`$
`$
`$
`$
`
`Amount owed to your
`spouse
`$
`$
`$
`$
`
`
`
`7.
`
`
`State the persons who rely on you or your spouse for support.
`
`Name [or, if a minor (i.e., underage), initials only] Relationship
`
`
`
`
`
`
`
`Age
`
`
`
`
`
`
`8.
`
`
`
`Estimate the average monthly expenses of you and your family. Show separately the
`amounts paid by your spouse. Adjust any payments that are made weekly, biweekly,
`quarterly, semiannually, or annually to show the monthly rate.
`
`You
`$
`
`
`Rent or home-mortgage payment (including lot rented for
`mobile home)
`[ ] Yes [ ] No
`
`Are real estate taxes included?
`[ ] Yes [ ] No
`
`Is property insurance included?
`Utilities (electricity, heating fuel, water, sewer, and telephone) $
`Home maintenance (repairs and upkeep)
`$
`Food
`$
`Clothing
`$
`Laundry and dry-cleaning
`$
`Medical and dental expenses
`$
`
`Your Spouse
`$
`
`$
`$
`$
`$
`$
`$
`
`
`
`- 4 -
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`

`

`Case 1:14-cv-02396-PGG-SN Document 304-1 Filed 04/24/24 Page 9 of 10
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`$
`Transportation (not including motor vehicle payments)
`$
`Recreation, entertainment, newspapers, magazines, etc.
`Insurance (not deducted from wages or included in mortgage payments)
`
`Homeowner's or renter's:
`$
`
`Life:
`$
`
`Health:
`$
`
`Motor vehicle:
`$
`
`Other:
`$
`Taxes (not deducted from wages or included in mortgage
`$
`payments) (specify):
`Installment payments
`
`Motor Vehicle:
`
`Credit card (name):
`
`Department store (name):
`
`Other:
`Alimony, maintenance, and support paid to others
`Regular expenses for operation of business, profession, or
`farm (attach detailed statement)
`Other (specify):
`
`Total monthly expenses:
`
`$
`$
`$
`$
`$
`$
`
`$
`$
`
`$
`$
`
`$
`$
`$
`$
`$
`$
`
`$
`$
`$
`$
`$
`$
`
`$
`$
`
`
`
`9.
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`
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`
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`10.
`
`
`
`
`
`
`
`
`
`Do you expect any major changes to your monthly income or expenses or in your assets
`or liabilities during the next 12 months?
`
`[ ] Yes
`
`[ ] No
`
`If yes, describe on an attached sheet.
`
`Have you spent — or will you be spending —any money for expenses or attorney fees in
`connection with this lawsuit? [ ] Yes [ ] No
`
`If yes, how much? $ ____________
`
`- 5 -
`
`

`

`Case 1:14-cv-02396-PGG-SN Document 304-1 Filed 04/24/24 Page 10 of 10
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`Provide any other information that will help explain why you cannot pay the docket fees
`for your appeal.
`
`Identify the city and state of your legal residence.
`
`City __________________________ State ______________
`
`Your daytime phone number: ___________________
`
`Your age: ________ Your years of schooling: ________
`
`Last four digits of your social-security number: _______
`
`11.
`
`
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`
`
`
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`12.
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`
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`- 6 -
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